Intake Form


Please complete the following form and answer all questions before arriving for your appointment.

Be sure to include your insurance information.
We'll see you soon!

Patient Information

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*This information is requested due to Healthcare Reform laws dictated by Congress.

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Social History

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Family History

Which family members had the below medical conditions? (father, mother, sibling, etc.)

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Insurance Information

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Emergency Contact

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Responsible Party (if minor patient)

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View Privacy Policy

Consent for Treatment and Acknowledgement of Policies

For any insurance plan that requires authorization from a primary care physician (e.g. HMO, PPO, etc.) it is your responsibility (as patient or guardian) to be sure that this office receives all necessary referrals or authorizations PRIOR to treatment. Professional services are rendered and billed directly to your insurance carrier; however you, the patient/guardian, are directly responsible for services rendered by the doctor. A health insurance policy is a contract between you (the patient or subscriber) and your insurance carrier. You MUST notify this Office of any changes to your insurance policy including policy termination, changes in co-payments or a new insurance policy. If for any reason the insurance carrier denies charges, payments for any services rendered will become the responsibility of the patient/guardian.
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All office visit charges and co-pays are due at the time services are rendered. It is the patient who is responsible for any and all financial aspects of services rendered. There will be a charge for returned checks, missed appointments without 24 hours notice and completion of any forms. I agree to pay for all deductibles, co-pays, non-covered services and any portion of covered services not paid in full by my insurance plan and understand that such payments are due at the time of service or immediately upon presentation of the bill. I hereby name Carolina Foot & Ankle Specialists (CFAS) as my assignee. I instruct my health care benefits plan administrator, i.e. PLAN to pay CFAS directly for all professional and medical services provided by CFAS through the means of electronic funds transfer(s) (EFT) or by check(s) made payable to and mailed to CFAS. I AUTHORIZE THE RELEASE OF ANY MEDICAL INFORMATION NECESSARY TO PROCESS CLAIMS.
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The above information is correct to the best of my knowledge. I understand that throughout my treatment, I am responsible for notifying the physician and/or medical staff of any and all updates to the information listed above. I also give permission for photographs of my feet to be taken that are to be kept as part of my medical record only. They will not be published as part of medical research or disbursed in any way without my permission.
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I acknowledge that I was provided a copy of the Notice of Privacy Practices for Carolina Foot & Ankle Specialists and I have read (or had the opportunity to read if I so choose) and understood the Notice.
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FINANCIAL POLICY

Your insurance policy is a contract that exists between you and your insurance company. Our relationship is with you, the patient and not the insurance company. If you have questions about your policy, please call the phone number provided on the back of your insurance card. The patient or responsible party is responsible for their bill being paid in full. Please inform us at every visit of any changes to your insurance coverage.

COPAYMENTS: It is a requirement of your insurance company that we collect your co-pay.
Payment is required upon checkout.

DEDUCTIBLES & CO-INSURANCE: If you are a NEW OR EXISTING PATIENT a $175 deposit will be collected at the time of the visit which will apply towards your deductible and co-insurance. Any remaining balance after submission to your insurance company is your responsibility. Medicare patients are not required to pay the $175 deposit fee.

SELF-PAY: Full payment is due at time of service. At a minimum, an evaluation and management fee will be charged. Additional procedures/services may be recommended by the doctor but you will be informed of these charges before proceeding with treatment.

REFERRAL: If your insurance plan requires a referral from your primary care doctor, this will be required at the time of your visit. Without a referral available, we may need to reschedule your appointment.

NO SHOW: 24 hours notice is required for cancellation of your appointment and failure to do so will incur a $25 fee. Failure to provide 24 hours notice of a procedural visit will incur a $50 fee.

FMLA/DISABILITY/MEDICAL RECORDS: There is a $25 charge for completion of these forms. There is a $25 fee to obtain a copy of your medical records. There is a charge of $15 for an x-ray disk.

PAYMENT RESPONSIBILITIES

We are pleased to welcome you to our office. New Patients are always appreciated. Our practice has grown as a result of its excellent relationship with our referring doctors and patients. As our patient, please feel free, at any time, to express any concerns or to ask any questions that you may have for the doctor or our staff. In order to assist you in making payment(s) for your podiatric treatment, the following options are listed. Please read them carefully and feel free to discuss them with us.

If you DO NOT have insurance: Payment is due, in full, at the time treatment is provided.

*For your convenience, we accept all major credit/debit cards and cash.

If you have Insurance: The percentage of coverage by your insurance company may be based on your insurance company’s own reduced fee schedule for medical services and may be less than actual charges resulting in lower coverage for you. Carolina Foot & Ankle Specialists has no control over this situation. Lower payment is a direct result of the plan selected by you or your employer. Please be advised that we cannot waive co-payment. We are required by law to collect co-payment.

Commercial Insurance: We will submit your claim to your insurance carrier for you. You are responsible for any deductible or co-payment not covered by your insurance. Once our office has received payment from the insurance company, you will be billed, with 30 day terms, for any amount still owed. You may choose to keep a credit card on file for those balances left to you by your insurance company.

Medicare: This office accepts Medicare assignment.

You have the option to upload images of your Driver's License and/or Government ID and Insurance card if you want but it is not required.

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Please ensure you have completed all mandatory fields on this form (indicated with an (*) asterisk next to the field) and please wait until our thank you page loads to ensure the form was successfully submitted otherwise your data will be lost. Please make sure when submitting your form to look out for the confirmation from the office that we have received your form.